Marketplace intake and enrolment record

1.

Appointment

I, the applicant, give my permission to Edward Gudas to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:

1. (a)Searching for an existing Marketplace application;
2. (b)Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums;
3. (c)Providing ongoing account maintenance and enrollment assistance, as necessary; or
4. (d)Responding to inquiries from the Marketplace regarding my Marketplace application.

2.

Limits on use and disclosure

I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.

3.

Accuracy, scope and revocation

I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by e-mailing Edward at [email protected].

1.

Review

I have reviewed the household, income, prescription, provider and plan information set out in the schedule above, and I have corrected anything that was wrong.

2.

Attestation

I attest that the information recorded is true, correct and complete to the best of my knowledge. I understand that the information I give will be used to determine eligibility for a Qualified Health Plan and, where applicable, for advance payments of the premium tax credit and cost-sharing reductions.

3.

Reconciliation

I understand that any advance payment of the premium tax credit is an estimate based on the income I have reported, that it is reconciled against my actual income on IRS Form 8962 when I file, and that I must report a change in income, household size or address to the Marketplace within 30 days.

4.

Demonstration

I understand that Gradepoint Insurance Group, LLC is named on this form as an illustration and that this page is a software demonstration: signing it transmits no application to the Marketplace, to CMS, or to any carrier, and creates no coverage of any kind.